Michigan State Medical Society held their annual House of Delegates meeting this past weekend, with some exciting developments on the state level, the most groundbreaking being the first state policy in opposition to USMLE Step2CS. For most doctors in attendance, this was the first they’d heard of the new Step exam, now required of all medical students. The test, initially created for international graduates, has been required for all medical school graduates since 2004 but recently gained national attention through the hard of work of Harvard medical students in the EndStep2CS petition campaign. The unnecessary costs and outrageous executive salaries are researched extensively at the Step2CS website, it is stunning to see what these examination boards are getting away with. It’s not just AMBS and MOC, this is industry-wide rot and corruption. The EndStep2CS video sums it up:

There are many ways to fight back against these testing corporations, but it is definitely an uphill battle and hard to know where to start. The MSMS resolution, written by University of Michigan 3rd year student Andrew Zureick, and introduced with Michigan State University 4th year Nicholas Harrison and Wayne State University 3rd year Tamara Roumayah has a very innovative solution to the problem. Rather than simply ask for elimination of the test, they put the onus back on the medical schools. They ask that passage of a school-based clinical skills equivalent count as Step2CS. This is a smart solution, because it returns responsibility back to the medical schools and takes power away from the testing corporations, while still holding clinical skills education and competency to the highest standards. I encourage all medical student delegates to use this model language in your own House of Delegates, and for physician delegates to present and defend these resolutions on behalf of the students.

However, this resolution did not pass easily, and there are lessons learned in Michigan for other student and physician delegates pursing similar resolutions in their state medical societies. The resolution was initially rejected by the committee, who felt a better solution would be to advocate for lower costs and increased testing sites. I cannot blame the committee entirely, this resolution was submitted as a late resolution, so they were not able to review the extensive research before testimony and deliberations. This was the first time anyone on the committee had heard of Step2CS, so it was a lot to wade through quickly.

The resolution was extracted and taken to a vote of the full house of delegates, eventually passing after vigorous debate, with amendments to remove the first two resolveds dealing with state level action (final action summary below). Testimony on the floor was very revealing. The majority of doctors, recognizing the parallels with MOC, supported the students. However, those in medical school administration strongly supported Step2CS. I found this interesting, I would’ve thought medical schools would resent having their curriculum hijacked and having to “teach to the test”. Seeing how most medical school Clinical Skills exams are far more rigorous, I would’ve thought passing a school exam would be a welcome option to alleviate one more burden on their students and being able to advertise a qualified Clinical Skills exam that trumps Step2CS would be a major marketing point to potential students and donors.

Instead, I was shocked to hear administrators wanted this test as an “outside measure” of their students. They felt they had a “conflict of interest”, not to fail their students who were paying so much to attend. This is frightening. No one is entitled to become a doctor, just because they pay tuition. Our medical schools have a moral responsibility to fail unqualified students, residency programs should not graduate incompetent doctors. It is unconscionable to fall for political correctness and not want to offend anyone, hoping some national test will do the job we should be doing in educating the next generation of physicians. Discriminating against incompetent students is essential, not something to be feared. Discrimination in this sense is otherwise known as discernment, to distinguish and select what is true, appropriate, and excellent.

Secondly, I was shocked to see some medical students defend the test, claiming the need for accountability and a desire to be tested. When students stop questioning, and instead accept and crave bureaucracy, we’re in a dangerous place in American medicine. I’m used to hearing administrative doctors justify certification schemes and “quality” reporting measures, I was just dismayed to see this start so young. I couldn’t help but think of Dr. Hendricks from Atlas Shrugged:

“Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it — and still less safe, if he is the sort who doesn’t.”

This strain of conformist behavior is another reason why we need organizations like Benjamin Rush Institute to encourage independent thinking among medical students. I am very proud of the student and physician delegates of the Michigan State Medical Society for coming together to pass the first state resolution dealing with Step2CS. I hope other state societies can move this forward, improving upon what we’ve started. Andrew Zureick, Tamara Roumayah, and Nicholas Harrison have done the heavy lifting for everyone, now go forth and multiply their efforts.

Final Action Summary-May 1, 2016

Transfer of Jurisdiction over Required Clinical Skills Examinations to LCME-Accredited and COCA-Accredited Medical Schools in Michigan – Full text here

The Committee recommended disapproval. They believed that a better solution would be to advocate for more testing sites and mitigating costs. Additionally, the Committee was concerned that other states may not accept students for residency programs or licensing if Step 2 CS was eliminated in Michigan. Committee testimony suggested a better option would be to expand testing sites, lowering costs, and offering better scheduling.

The Resolution was extracted on the Floor. The House of Delegates amended the resolved portion(s) to read:

RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask the AMA to work with the Federation of State Medical Boards and state medical licensing boards to advocate for the elimination of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) exam and the COMLEX Level 2-PE (Performance Evaluation) as a requirement for Liaison Committee on Medical Education-accredited and Commission on Osteopathic College Accreditation-accredited medical school graduates who have passed a school-administered, clinical skills examination; and be it further

RESOLVED: That the Michigan Delegation to the American Medical Association (AMA) ask the AMA to amend D-295.998 by insertion (bold) and deletion 588 (strikethrough) as follows:

Required Clinical Skills Assessment During Medical School D-295.988

Our AMA will advocate thatencourage its representatives to the Liaison 592 Committee on Medical Education (LCME) and the American Osteopathic Association Commission on Osteopathic College Accreditation (COCA)to ask the LCME, to 1) determine and disseminate to medical schools a description of what constitutes appropriate compliance with the accreditation standard that schools should “develop a system of assessment” to assure that students have acquired and can demonstrate core clinical skills, and 2) require that medical students attending LCME-accredited or COCA-accredited institutions pass a school-administered clinical skills examination to graduate from medical school.

About Meg Edison MD

Comments

Superb reporting , Meg! And even better work at the legislative level. We will pursue this in Texas using your model, shared experience, and wisdom. With central planners and bureaucrats in a perpetual state of frenzy at the national level, the States remain our last bastion of liberty and sanity. Thank you for all you do to protect our patients and profession.

This is inspirational! I think we can keep this ball rolling to end corruption on all the testing and expenses that are unfairly burdened upon physicians, and make this profession accessible and rewarding once again. You and these amazing students just showed us how.

OMS-1 here.
Just making sure I understand this. The reasoning for petitioning against USMLE Step 2 CS / COMLEX Level 2 PE is because of the cost of the test, the salary of the bureaucrats involved, testing locations, and that it is a relatively new (12 y.o.) standardised examination?

I get it. It’s a bugbear, especially for someone with few resources, like myself. The thing is, it’s a growing pain indicative of an ideology shift that has been happening in the US for the past couple decades. There is a growing trend within the US towards greater centralisation and federal oversight/involvement. Right now, we exist in an awkward stage, in between decentralised, free-market capitalism and socialised service delivery. Either end of the spectrum works, but where we are currently, centralised, limited-market capitalism, benefits no-one but the business-minded and administratively inclined. To go backwards, towards the decentralised system, is antithetical, detrimental even, to today’s bureaucrats, whereas, within a socialised system, there is the possibility of highly lucrative government contracts.

Realistically, matters are going to progress in that direction. The movement has already gained enough momentum. All that we would be able to do is to slow it. Some aspects of this fight, like the MOCs, we stand a chance at changing, because, in truth, we are acting prophylactically. If we truly wanted to roll back certain standardisations, limited patient interaction time, EMRs, insurance compensation, or other such problems, we would need for the vox populi to change, but the impetus to change is caused by knowledge and knowledge is in the hands of those who prefer things to stay as they are.

In a sense, such issues are comparable to preventable, but chronic diseases, for instance, HIV. They can be prevented if we are vigilant, but, if given the opportunity to exist, to take root, then we are left attempting to arrest its progress.

I do not mean to be a downpour on the parade, but I do not foresee much change in this specific case. We are better off pooling our collective energies against MOC/MOL and the actions of our various governing boards, especially using arguments outside of bureaucrat/administrator salaries. While they are true, we risk becoming a broken record on an argument the general public is less able to empathise with, especially when they are being fed the rhetoric of quality metrics.

“Right now, we exist in an awkward stage, in between decentralised, free-market capitalism and socialised service delivery. Either end of the spectrum works,” Socialism never works. All it does is shift cost from one person or entity to another. It stifles innovation. It limits freedom. It asks for more and more but ultimately provides less and less. It keeps afloat what should be drowned. It’s a feel good rather than an objective good. Don’t repeat the government lies by giving it credibility.

I didn’t say socialism was a good thing. I merely stated where we are. What we are approaching is a socialised service delivery. That does’t imply that there’s no delivery under capitalism, merely that we are shifting from a plurality to a singularity.

Personally, I’m against socialism because it removes the agency of the individual and community to care for those in need within their community.

Pardon my confusion. If socialism is on one end of the spectrum, and either end of the spectrum works, then socialism should work. So why wouldn’t socialism be a good thing? It’s because humans aren’t a singularity. We each have unique desires, but when one persons desire intrudes on another persons right to be left alone, that is where problems arise. For instance, why is it illegal to live “off the grid”? Is it because of what America became: Of some people, by some people, for some people?

Socialism only works in a society in which every individual is invested in their community. As such, it works best in smaller units, a tribal model, if you will. The larger the population, the more invisible the “sharing” becomes and the more independent the individuals will be, as individuals rely less and less on their direct neighbours.

Our society is trying to drift towards socialism out of conscience, not practicality. They like the apparent image of everyone being provided for and nobody falling through the cracks, but they are relying on the wrong body to oversee that. Charity and community are the local, non-governmental sources of social justice and welfare, but everyone today is expecting the govt to fill that role. Hence, we are stuck in our awkward conundrum of wanting the freedom from the govt of conservative capitalism and wanting the welfare and oversight of socialism.

As for living off the grid, I presume it’s akin to America’s aversion to walking barefoot. With bare feet, people assume you are tracking in more germs and grime, but you are carrying roughly the same amount as you would with shoes. The only person at any greater danger is yourself, yet others dictate how you should act for their peace of mind.
Similarly, when people go off the grid, they are removing themselves from the standard comitatus of society, prompting people to look askance at individuals wanting to separate themselves entirely and the government, having decreased ability to keep tabs on/control you via utilities and general usage, begins getting paranoid that you are up to no good.

What you’re expressing, though, is a very common first-world perspective of self-reliance, self-sufficiency, and a desire of independence. In other parts of the world, especially community-centric third-world countries, such a desire would draw even more concerned, suspicious glances than it does here.

Socialism doesn’t work in any modern society because a critical mass of people possess knowledge and have imagination. Our society is drifting toward socialism by force. Government is the definition of force and the sheep who enable it are freeloaders who believe it is their right to feed off of the fruits of others labor. As for what the rest of the world thinks I really don’t care. You really have to want to be free in order to have any chance of attaining it. Being a mental slave is not what a thinking human should seek.

The likely reason for administrators to support using the USMLE for clinical skills evaluation is the same reason pop stars use TicketMaster: it redirects anger from the medical school administration to an opaque and inscrutable corporate behemoth.

If you fail clinical skills testing at your school and that is what is keeping you from graduating, you have an office door to scream at and names to list on your lawsuit for subjective discrimination. On the other hand, if you fail Step 2CS, you don’t have many reasonable options to contest that, and you just sign up to take it again. The Med school commiserates and pats you on the back and thanks their lucky stars that they weren’t the ones to have to tell you that you give off a weird vibe.